Cost-Effectiveness of Adult Hepatitis A Vaccination Strategies in Korea Under an Aging Susceptibility Profile

Hepatitis A severity increases sharply with age, while Korea is experiencing a cohort shift in which low seroprevalence adult cohorts are aging into older, higher fatality age groups. This demographic and immunological transition creates an urgent policy question regarding how adult vaccination should be prioritized under resource constraints. We evaluated three adult vaccination scenarios targeting low seroprevalence age groups (S1) 20 to 39 years, (S2) 40 to 59 years, and (S3) 20 to 59 years. Using an age structured dynamic transmission model calibrated to Korean data, we derived dynamically feasible vaccination allocation trajectories under realistic capacity constraints using an optimal control framework and linked these trajectories to long term transmission model simulations. We conducted DALY based cost effectiveness analyses over a lifetime horizon from both healthcare system and societal perspectives, and characterized uncertainty using probabilistic sensitivity analysis (PSA) and cost effectiveness acceptability curves (CEACs). Robustness was examined using one way sensitivity analyses. In the base case, S2 consistently yields the most favorable and robust cost effectiveness profile under both perspectives, with the lowest ICER. S3 achieved the largest reduction in DALYs but requires substantially higher incremental costs, resulting in a higher ICER than S2. S1 produces the smallest DALY reduction and is the least efficient strategy. PSA and CEACs confirm that S2 remains the preferred option across most willingness to pay ranges. S2 offers the most balanced and robustly cost effective strategy in Korea, capturing substantial mortality reduction while limiting additional program costs. S3 may be justified when higher budgets or willingness to pay thresholds are acceptable, but S2 provides the clearest value for money under epidemiological and economic conditions.